Borderline Personality Disorder: Clinical Guidelines for Treatment (Stone, 2019)

The inclusion of “Borderline Personality Disorder: Clinical Guidelines for Treatment” in the 50th anniversary volume serves as a veritable guide for the perplexed psychiatrist. The designation of borderline personality disorder (BPD) originated in the late 1930s and has been a subject of controversy for decades, reminiscent of the proverbial blind men and the elephant. In this instance, the researchers promulgate their own particular theoretical constructs and treatment approaches, often negating the diverse perceptions of the others.

Dr. Stone, with over fifty years as a clinician/researcher, presented a unique perspective in that not only had he studied the voluminous papers of the past and present borderline theorists, but he had also treated or supervised myriad patients over many years. He concluded that BPD is a psychiatric disorder, not a true personality disorder such as schizotypal, which is closely linked with schizophrenia, or dependent or compulsive disorders, which need not be accompanied by identifiable symptoms. Many BPD patients, he noted, may eventually be diagnosed with either bipolar I or bipolar II disorder. He suggested that the clinician take a careful family history of first- and second-degree relatives because of the gradations of genetic risk for serious mental illness. In all cases, the gene-environment interaction is paramount.

The 12 illustrative vignettes presented differ markedly in symptomatology, etiology, and treatment choice. For example, one patient presented with severe depression and self-harm, mood lability, inordinate anger, tempestuous interpersonal relationships, stress-related paranoid ideation, and fear of abandonment. There was pronounced genetic risk in terms of severe depression and suicide in family members.

Another patient had experienced traumatic childhood events, including incest and maternal neglect, with unknown genetic risk factors.